Acta Paediatrica. 2020;00:1–7. wileyonlinelibrary.com/journal/apa
|
11 | BACKGROUND
Coeliac disease is a common genetic autoimmune disease that is char-acterised by a permanent intolerance to gluten. The only effective treatment for coeliac disease is a life-long gluten-free diet, which in most patients leads to the recovery of the damaged mucosa of the small intestine.1 The prevalence of coeliac disease has commonly been
reported to be around 1% in Western populations,2 but there are also studies that have shown a prevalence as high as 2%-3% in Finland and Sweden.3,4 Moreover, screening studies have revealed that the major-ity of coeliac disease patients are undiagnosed.4,5 It is widely known that the risk of having coeliac disease is strongly linked to genetics and that the human leucocyte antigens of isotype DQ2 and DQ8 are necessary to develop the disease.1 However, not all persons who are Received: 8 June 2020
|
Revised: 17 August 2020|
Accepted: 26 August 2020DOI: 10.1111/apa.15562
R E G U L A R A R T I C L E
Family socio-economic status and childhood coeliac disease
seem to be unrelated—A cross-sectional screening study
Fredrik Norström
1| Fredinah Namatovu
2| Annelie Carlsson
3|
Lotta Högberg
4| Anneli Ivarsson
1| Anna Myléus
1,5This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2020 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica
Abbreviations: ETICS, exploring the iceberg of celiacs in Sweden; CD, Coeliac disease. 1Department of Epidemiology and Global
Health, Umeå University, Umeå, Sweden 2Department of Historical, Philosophical and Religious Studies, Umeå University, Umeå, Sweden
3Department of Pediatrics, Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
4Department of Paediatrics, Norrköping Hospital, Linköping University, Norrköping, Sweden
5Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
Correspondence
Fredrik Norström, Department of Epidemiology and Global Health, Umeå University, SE-901 87 Umeå, Sweden. Email: fredrik.norstrom@umu.se Funding information
This study was funded by the Swedish Research Council, the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, the Swedish Council for Working Life and Social Research, the Swedish Coeliac Association's research fund and Västerbotten County Council.
Abstract
Aim: The aim of our study was to examine whether there is a difference in coeliac
disease prevalence in regard to parents' education level and occupation, and whether this differs between screened and clinically diagnosed children at the age of 12 years.
Methods: The study, Exploring the Iceberg of Celiacs in Sweden (ETICS), was a
school-based screening study of 12-year-old children that was undertaken during the school years 2005/2006 and 2009/2010. Data on parental education and occu-pation were reported from parents of the children. Specifically, by parents of 10 710 children without coeliac disease, 88 children diagnosed with coeliac disease through clinical care, and 231 who were diagnosed during the study.
Results: There were no statistically significant associations between occupation and
coeliac disease for either the clinically detected (prevalence ratio 1.16; confidence in-terval 0.76-1.76) or screening-detected coeliac disease cases (prevalence ratio 0.86; confidence interval 0.66-1.12) in comparison with children with no coeliac disease. Also, there were no statistically significant associations for parental education and coeliac disease diagnosis.
Conclusion: There was no apparent relationship between coeliac disease and
socio-economic position. Using parents' socio-socio-economic status as a tool to help identify children more likely to have coeliac disease is not recommended.
K E Y W O R D S
genetically predisposed go on to develop coeliac disease, which raises more questions on the aetiology of the disease. There is limited knowl-edge about other factors that are linked to the development of coeliac disease, although environmental factors such as infant feeding prac-tices and infections have been associated with disease development.6-8 Some studies on the aetiology of coeliac disease have investi-gated the role of socio-economic factors such as occupation, income and education, but evidence is still sparse and in some cases con-tradictory.9-20 The hygiene and the microflora hypotheses provide a groundwork for understanding the role of environmental factors in the aetiology of coeliac disease.21 These are supported by some studies on coeliac disease.10,22
It has been shown that coeliac disease is more prevalent among school children in a part of Finland where the socio-economic status is higher than in a comparable population in the adjacent Russian Karelia.10 However, a study from southeast England showed that be-longing to a low socio-economic class increased the risk of coeliac disease.16 A Swedish biopsy-based study reported only a weak asso-ciation with a low occupation status, while no assoasso-ciation with ed-ucation level was identified, despite having over 29 000 diagnosed coeliac disease cases.14 Also, other Swedish studies present some links between an increased risk of coeliac disease for children and their parents’ in a lower socio-economic strata.11,13,19,23
On the other hand, in another Swedish study that included all coeliac disease cases diagnosed between 1998 and 2003, an in-creased risk of childhood coeliac disease was shown to be strongly associated with higher income.13 Also, two studies in the United Kingdom showed that coeliac disease was more common in areas with a higher mean income.18,20 Similarly, a Dutch study, which did not include individual socio-economic factors, showed that coeliac disease was more common when those diagnosed during childhood lived in an area where the overall socio-economic status was higher than those diagnosed during adulthood.9
Even though studies have provided evidence on the association between socio-economic status and coeliac disease, these results are still contradicting, and they have not focused on screening-de-tected coeliac disease cases. The observed differences in coeliac disease prevalence might imply different rates of clinical diagnosis rather than a direct influence on the aetiology of coeliac disease. No investigation has yet studied a larger population of individuals diagnosed through screening.
The aim of our study was to examine whether there is a differ-ence in coeliac disease prevaldiffer-ence in regard to parents’ education level and occupation, and whether this differs between screened and clinically diagnosed children at the age of 12 years.
2 | PARTICIPANTS AND METHODS
2.1 | Study material
For the current study, data from the Exploring the Iceberg of Celiacs in Sweden (ETICS) study was used. This study was a multi-centre
cross-sectional school-based screening of coeliac disease among 12-year-olds in Sweden. ETICS was conducted during the school years 2005/2006 and 2009/2010 in five different regions.24 A total of 18 325 children were invited, of whom 13 279 children par-ticipated. A total of 100 children already had a diagnosis of coeliac disease through clinical care before the study started, and an ad-ditional 242 children were diagnosed with coeliac disease following the screening.4,24
At the time of the screening, and before the result of the blood sample were known, parents or other legal guardians of the partici-pating children were asked to respond to a questionnaire. The ques-tionnaire was sent to their home with two reminders, and a prepaid envelope addressed to the study administration. From this question-naire, we used responses from the parents about their current labour market status, their current or most recent occupation, and their ed-ucation level. In total, 11 239 (85%) of 13 279 parents in the ETICS study responded to the questionnaire.
The Regional Ethical Review Board of Umeå University approved the ETICS study.
2.2 | The questionnaire
Socio-economic status was defined based on three questions. The first question measured education level with five alternatives: <9 years at school, finished primary school, which corresponds to 9 years of school, finished upper secondary school, which cor-responds to 12 years of school, at least 1 year of education after upper secondary school and university diploma. The second ques-tion asked about the parents' labour market status with the fol-lowing response alternatives: currently employed, self-employed, student, unemployed more or <6 months, working from home, parental leave and retired (either early-retired or age-retired). The third question asked the respondent to specify with words their current or most recent occupation. A socio-economic classification was obtained from these answers based on the socio-economic classification system defined by Statistics Sweden in 1982,25 both
Key notes
• Previous studies on socio-economic status and coeliac disease risk have shown contradicting results, and most of these studies are based on individuals clinically diag-nosed, thus a minority of all cases.
• From a population-based screened cohort, we found no evidence that socio-economic status is associated with the risk of developing coeliac disease.
• There was no apparent gender difference in the associa-tion between socio-economic status and coeliac disease prevalence.
for each parent individually and for the highest classification be-tween them. Codes for occupations were divided into the follow-ing groups: students 1-3, manual workers 11, 12, 21, 22 and 86-89, non-manual workers with low educational demand 33-36, 76, 77
and 79, non-manual workers with intermediate educational demand 46, and non-manual workers with high educational demand 56, 57, 60 and 78. The highest parental occupation of the child's parents was chosen according to the instructions from Statistics Sweden.
Clinical CD (n = 88) Screened CD (n = 231) No CD (n = 10 710) n % n % n % Participants (n = 11 029) Boys (n = 5608) 30 34 101 44 5477 51 Girls (n = 5421) 58 66 130 56 5233 49 Mother's occupation (n = 10 189) Student (n = 424) 6 7.1 5 2.3 413 4.2 Manual worker (n = 3063) 31 36 56 26 2976 31
Non-manual worker with low educational demand (n = 1923)
15 18 49 23 1859 19
Non-manual worker with intermediate educational demand (n = 2939)
22 26 56 26 2861 29
Non-manual worker with high educational demand (n = 1840)
11 13 51 24 1778 18
Household occupation (n = 10 420)
Student (n = 115) 0 0 1 0.5 114 1.1
Manual worker (n = 2331) 26 30 39 18 2266 22
Non-manual worker with low educational demand (n = 2317)
16 19 51 23 2250 22
Non-manual worker with intermediate educational demand (n = 2402)
19 22 50 23 2333 23
Non-manual worker with high educational demand (n = 3255)
25 29 78 36 3152 31
Mother's educational level (n = 10 597) Less than 9 y at school
(n = 180) 1 1.1 1 0.5 178 1.7
Primary school (n = 739) 9 10 11 5.0 719 7.0
College (n = 3098) 21 24 76 35 3001 29
At least 1 y of education after college (n = 1941)
16 18 36 17 1889 18
University diploma (n = 4639) 40 46 94 43 4505 44
Household educational level (n = 10 770)
Less than 9 y at school (n = 97) 0 0 1 0.5 96 0.9
Primary school (n = 419) 6 6.8 8 3.6 405 3.9
College (n = 2844) 22 25 57 26 2765 26
At least 1 y of education after
college (n = 1935) 16 18 42 19 1877 18
University diploma (n = 5475) 44 50 113 51 5318 51
TA B L E 1 Characteristics of the
population divided into coeliac disease (CD) groups
2.3 | Statistical analysis
Descriptive statistics are presented using frequency tables, cross-tabulations, and mean and median values. Associations between coeliac disease prevalence and socio-economic factors were ana-lysed with prevalence ratios. In our analyses, we included children who had a coeliac disease diagnosis either before, referred to as clinical coeliac disease, or during the ETICS screening study, re-ferred to as screened coeliac disease, or had a blood sample that did not indicate presence of coeliac disease, referred to as no liac disease. We also combined the first two groups into any coe-liac disease to compare with no coecoe-liac disease. In our analyses, the categories of manual worker and non-manual worker with low educational demand were combined and referred to as low-skilled workers, while the other categories for non-manual workers were combined and referred to as high-skilled workers. Furthermore, education level was divided into no university degree and univer-sity degree. The category of students was excluded in the analyses because the group had mixed education levels and different oc-cupational backgrounds.
Statistical significance was defined at the 5% level. Microsoft Access was used for data handling. Stata 13.1 (StataCorp LP) was used for descriptive statistics. Prevalence ratios were calculated with WinPepi 11.65, including results for boys and girls separately, using the tradi-tional log-transformation method to estimate confidence intervals.26
3 | RESULTS
There were 11 029 parents who responded to the questionnaire and whose child belonged to one of the three groups: clinically di-agnosed, screening diagnosed or no coeliac disease. We excluded responses to the questionnaire from 161 parents to children who had no previous coeliac disease diagnosis and who did not provide a blood sample and 49 parents to children who were referred to a biopsy due to positive serology without having a confirmed coeliac disease diagnosis.
In both coeliac disease groups, there was a higher proportion of girls than boys with a coeliac disease diagnosis (Table 1). A similar observation was made in a previous article from the ETICS study.24 The relationship between occupation level and education with coe-liac disease diagnosis is also presented in Table 1.
There were no statistically significant relationships between occupation and coeliac disease when we analysed the data for ei-ther of the coeliac disease groups in comparison with children with no coeliac disease, regardless of whether we used household or mother's occupation (Table 2). Furthermore, there was no statisti-cally significant relationship between any coeliac disease, whether screening-detected or clinically diagnosed, and any of the socio-eco-nomic measures (Tables 2 and 3). There was a numerical indication that those with lower socio-economic status were often diagnosed clinically, while screening-detected coeliac disease was common if parents had a higher socio-economic status. Also, for education level, there were no statistically significant relationships with the different coeliac disease groups (Table 3). The pattern for the preva-lence ratios was similar as for occupation with estimates showing an even lower effect with prevalence ratios being closer to 1.
When the results were calculated for boys and girls separately, we found no statistical significance for either occupation or educa-tion (Tables 4 and 5). However, it was more common to have clin-ically diagnosed coeliac disease among boys whose parents had a higher occupation, as well as a longer education, while the opposite was observed for girls. For children who were diagnosed with co-eliac disease through the ETICS study, there was a non-significant increased risk for coeliac disease for girls whose parents had high-skilled worker as the highest occupation.
4 | DISCUSSION
This study of 10 819 parents whose children had a coeliac disease diagnosis either clinically or through screening found no evidence for any statistically significant relationships between occupation and education and coeliac disease. However, there was a numerical
Low-skilled workers High-skilled workers
Prevalence ratio (confidence interval) n % n % Household occupation Clinical CD 42 49 44 51 1.16 (0.76-1.76) Screened CD 90 41 128 59 0.86 (0.66-1.12) Any CD 132 43 172 57 0.93 (0.75-1.17) No CD 4516 45 5485 55 1 Mother's occupation Clinical CD 46 58 33 42 1.33 (0.85-2.08) Screened CD 105 50 107 50 0.94 (0.72-1.23) Any CD 151 52 140 48 1.03 (0.82-1.30) No CD 4835 51 4639 49 1
TA B L E 2 Association between coeliac
No university degree University degree Prevalence ratio (confidence interval) n % n % Household education Clinical CD 44 50 44 50 1.03 (0.68-1.57) Screened CD 108 49 113 51 0.99 (0.76-1.28) Any CD 152 49 157 51 1.00 (0.80-1.25) No CD 5143 49 5318 51 1 Mother's education Clinical CD 47 54 40 46 0.92 (0.60-1.39) Screened CD 124 57 94 43 1.03 (0.79-1.34) Any CD 171 56 134 44 0.99 (0.80-1.24) No CD 5787 56 4505 44 1
TA B L E 3 Association between coeliac
disease (CD) and education
TA B L E 4 Association between coeliac disease (CD) and occupation, divided according to the sex of the child
Boys Girls Low-skilled workers High-skilled workers Prevalence ratio (confidence interval) Low-skilled workers High-skilled workers Prevalence ratio (confidence interval) n % n % n % n % Household occupation Clinical CD 11 38 18 62 0.74 (0.35-1.57) 31 54 26 46 1.45 (0.94-2.23) Screened CD 43 46 50 54 1.04 (0.69-1.56) 47 38 78 62 0.74 (0.52-1.06) Any CD 54 44 68 56 0.96 (0.68-1.37) 78 43 104 57 0.92 (0.69-1.22) No CD 2306 45 2793 55 1 2210 45 2692 55 1 Mother's occupation Clinical CD 12 46 14 54 0.84 (0.39-1.81) 34 64 19 36 1.68 (0.96-2.93) Screened CD 49 54 41 46 1.16 (0.77-1.75) 56 46 66 54 0.80 (0.57-1.14) Any CD 61 53 55 47 1.08 (0.75-1.55) 90 51 85 49 1.00 (0.78-1.28) No CD 2441 51 2381 49 1 2394 51 2258 49 1
TA B L E 5 Association between coeliac disease (CD) and education, divided according to the sex of the child
Boys Girls Low-skilled workers High-skilled workers Prevalence ratio (confidence interval) Low-skilled workers High-skilled workers Prevalence ratio (confidence interval) n % n % n % n % Household education Clinical CD 11 37 19 63 0.60 (0.28-1.25) 33 57 25 43 1.37 (0.82-2.30) Screened CD 50 53 45 47 1.14 (0.76-1.69) 58 46 68 54 0.89 (0.63-1.26) Any CD 61 49 64 51 0.98 (0.69-1.38) 91 49 93 51 1.02 (0.77-1.36) No CD 2707 49 2776 51 1 2497 49 2606 51 1 Mother's education Clinical CD 12 41 17 59 0.55 (0.26-1.15) 35 60 23 40 1.18 (0.70-1.99) Screened CD 54 57 40 43 1.05 (0.70-1.58) 70 56 54 44 1.01 (0.71-1.43) Any CD 66 54 57 46 0.90 (0.64-1.28) 105 57 77 43 1.06 (0.79-1.41) No CD 2961 56 2306 44 1 2826 56 2199 44 1
indication that lower socio-economic status was related to an increased chance of being diagnosed clinically, while diagnosis through screening was more common if the parents had a higher socio-economic status. Despite inviting over 18 000 children to the study, we had limited number of children who were diagnosed with coeliac disease. Therefore, we remain cautious when present-ing conclusions about the relationship between socio-economic status and the risk of having coeliac disease, either clinically or by screening.
Our study was in line with previous studies that could not pro-vide statistical epro-vidence for an association between socio-economic status and the prevalence of coeliac disease. The observed numer-ical, but not statistically significant indication that lower socio-eco-nomic status was related to an increased risk of being diagnosed clinically follows the same pattern as seen in previous Swedish studies.11,13,19,23 However, we cannot relate the results for screen-ing-detected cases to previous studies in which they were clinically diagnosed. Some previous studies attributed health disparities ac-cording to socio-economic status to differences in help-seeking behaviours.27,28 Persons from deprived areas tend to be less likely to seek medical care and are potentially less likely to undergo co-eliac disease testing. Thus potentially explaining the higher coco-eliac disease incidence in areas with higher socio-economic status in the British studies.18,20 However, our findings did not support this stance as we observed a higher, although not significant, coeliac dis-ease prevalence for the group with lower socio-economic status in the clinical cases.
Our study does not promote efforts for case finding related to parental occupation or education. However, further research on socio-economic conditions and coeliac disease in populations with larger welfare gradients than Sweden and with privatised health care may be more suited to identify this association.
The hygiene and the microflora hypotheses provide a common explanation for the potential role of socio-economic status in coe-liac disease aetiology.21 In our study, we included all cases of coeliac disease, both clinical and screening-detected, thus eliminating the variations in coeliac disease risk attributed to differences in clinical diagnosis. We found no association between any coeliac disease and any of the socio-economic measures. These findings suggest that socio-economic status does not influence the risk of developing co-eliac disease.
To our knowledge, ours is the first study to assess the relation-ship between socio-economic status and coeliac disease risk with both clinically and screening-detected coeliac disease patients. The diagnosis of coeliac disease was biopsy verified for both clinically and screening-detected coeliac disease cases. A limitation of our study was that the geographical areas were not randomly chosen and they only covered around 10% of Swedish children. Consequently, the proportion of clinical cases might differ to other regions. However, a previous ETICS publication concluded that participating areas were representative of the whole population regarding socio-economic status.24 We therefore expect any differences to have negligible im-pact on our conclusions.
Almost 40% of the children invited to the ETICS study did not respond to the questionnaire. Participation might be high among already diagnosed children, while it is more unlikely among other children as they lack knowledge about coeliac disease. Moreover, 86% of the parents to children with clinically diagnosed coeliac disease answered the questionnaire, implying that results for them were representative. Previous reports show similarities between participants and non-participants in ETICS.4,24 It is therefore likely that non-participation had a negligible effect on the prevalence's for children without a coeliac disease diagnosis prior to our study. The measurements of parental education and occupation might affect our results because these were self-re-ported. However, parents reported this information in a stan-dard way. The occupation classifications are from a well worked through definition by Statistics Sweden,25 making it a reliable tool to use.
5 | CONCLUSION
There was no apparent relationship between coeliac disease and socio-economic status. However, there were some indications that children of a lower socio-economic background are more frequently being diagnosed clinically and that children of a higher socio-eco-nomic background to a greater extent have an undiagnosed coeliac disease later detected in the screening. Despite a large study sample, we could not confirm a dependency between socio-economic status and the risk of having coeliac disease.
ACKNOWLEDGEMENTS
We would like to thank all participating children and their families. Furthermore, we would like to thank the all the school personnel and the ETICS research team for their contributions.
CONFLIC T OF INTEREST
The authors report no conflicts of interest.
ORCID
Fredrik Norström https://orcid.org/0000-0002-0457-2175
Fredinah Namatovu https://orcid.org/0000-0001-5471-9043
Annelie Carlsson https://orcid.org/0000-0002-5608-3437
Lotta Högberg https://orcid.org/0000-0001-5966-9241
Anneli Ivarsson https://orcid.org/0000-0001-8944-2558
Anna Myléus https://orcid.org/0000-0003-2478-9598
REFERENCES
1. Lebwohl B, Sanders DS, Green PHR. Coeliac disease. Lancet. 2018;391:70-81.
2. Dubé C, Rostom A, Sy R, et al. The prevalence of celiac disease in average-risk and at-risk Western European populations: a system-atic review. Gastroenterology. 2005;128:S57-S67.
3. Mustalahti K, Catassi C, Reunanen A, et al. The prevalence of ce-liac disease in Europe: results of a centralized, international mass screening project. Ann Med. 2010;42:587-595.
4. Myléus A, Ivarsson A, Webb C, et al. Celiac disease revealed in 3% of Swedish 12-year-olds born during an epidemic. J Pediatr
Gastroenterol Nutr. 2009;49:170-176.
5. Fasano A, Catassi C. Current approaches to diagnosis and treat-ment of celiac disease: an evolving spectrum. Gastroenterology. 2001;120:636-651.
6. Lindfors K, Lin J, Lee HS, et al. Metagenomics of the faecal virome indicate a cumulative effect of enterovirus and gluten amount on the risk of coeliac disease autoimmunity in genetically at risk chil-dren: the TEDDY study. Gut. 2020;69:1416-1422.
7. Ludvigsson JF, Lebwohl B. Three papers indicate that amount of gluten play a role for celiac disease - But only a minor role. Acta
Paediatr. 2020;109:8-10.
8. Silano M, Agostoni C, Sanz Y, Guandalini S. Infant feeding and risk of developing celiac disease: a systematic review. BMJ Open. 2016;6:e009163.
9. Burger JP, Roovers EA, Drenth JP, Meijer JW, Wahab PJ. Rising inci-dence of celiac disease in the Netherlands; an analysis of temporal trends from 1995 to 2010. Scand J Gastroenterol. 2014;49:933-941. 10. Kondrashova A, Mustalahti K, Kaukinen K, et al. Lower economic
status and inferior hygienic environment may protect against celiac disease. Ann Med. 2008;40:223-231.
11. Ludvigsson JF. Socio-economic characteristics in children with coe-liac disease. Acta Paediatr. 2005;94:107-113.
12. Namatovu F, Olsson C, Lindkvist M, et al. Maternal and perinatal conditions and the risk of developing celiac disease during child-hood. BMC Pediatr. 2016;16:77.
13. Namatovu F, Strömgren M, Ivarsson A, et al. Neighborhood con-ditions and celiac disease risk among children in Sweden. Scand J
Public Health. 2014;42:572-580.
14. Olen O, Bihagen E, Rasmussen F, Ludvigsson JF. Socioeconomic po-sition and education in patients with coeliac disease. Dig Liver Dis. 2012;44:471-476.
15. Olsson C, Stenlund H, Hörnell A, Hernell O, Ivarsson A. Regional variation in celiac disease risk within Sweden revealed by the nationwide prospective incidence register. Acta Paediatr. 2009;98:337-342.
16. Roberts SE, Williams JG, Meddings D, Davidson R, Goldacre MJ. Perinatal risk factors and coeliac disease in children and young adults: a record linkage study. Aliment Pharmacol Ther. 2009;29:222-231.
17. West J, Fleming KM, Tata LJ, Card TR, Crooks CJ. Incidence and prevalence of celiac disease and dermatitis herpetiformis in the
UK over two decades: population-based study. Am J Gastroenterol. 2014;109:757-768.
18. Whyte LA, Kotecha S, Watkins WJ, Jenkins HR. Coeliac disease is more common in children with high socio-economic status. Acta
Paediatr. 2014;103:289-294.
19. Wingren CJ, Björck S, Lynch KF, Ohlsson H, Agardh D, Merlo J. Celiac disease in children: a social epidemiological study in Sweden.
Acta Paediatr. 2012;101:185-191.
20. Zingone F, West J, Crooks CJ, et al. Socioeconomic variation in the incidence of childhood coeliac disease in the UK. Arch Dis Child. 2015;100:466-473.
21. Bach JF. The hygiene hypothesis in autoimmunity: the role of pathogens and commensals. Nat Rev Immunol. 2018;18:105-120. 22. Lohi S, Mustalahti K, Kaukinen K, et al. Increasing prevalence of
coe-liac disease over time. Aliment Pharmacol Ther. 2007;26:1217-1225. 23. Myléus A, Hernell O, Gothefors L, et al. Early infections are associ-ated with increased risk for celiac disease: an incident case-referent study. BMC Pediatr. 2012;12:194.
24. Ivarsson A, Myléus A, Norström F, et al. Prevalence of child-hood celiac disease and changes in infant feeding. Pediatrics. 2013;131:e687–94.
25. Statistics Sweden. Socioekonomisk indelning (SEI). Statistics
Sweden. 1982;1982:4.
26. Abramson JH. WINPEPI updated: computer programs for epide-miologists, and their teaching potential. Epidemiol Perspect Innov. 2011;8:1.
27. Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167-194.
28. Kozyrskyj AL, Dahl ME, Chateau DG, Mazowita GB, Klassen TP, Law BJ. Evidence-based prescribing of antibiotics for children: role of socioeconomic status and physician characteristics. Can Med
Assoc J. 2004;171:139-145.
How to cite this article: Norström F, Namatovu F, Carlsson A,
Högberg L, Ivarsson A, Myléus A. Family socio-economic status and childhood coeliac disease seem to be unrelated—A cross-sectional screening study. Acta Paediatr. 2020;00:1–7.
